ACORD 25, Certificate of Liability Insurance Completed Form Examples and Samples

Explore detailed examples and filled samples of the ACORD 25 Certificate of Liability Insurance form. See how to correctly complete the form for various scenarios, including construction, with clear explanations of policy limits, additional insureds, and waivers of subrogation. Ideal for insurance professionals and businesses.
Fill out form with AI
Download PDF Example
Completed ACORD 25 Certificate of Liability Insurance for a construction company

ACORD 25 Example – Construction Contractor

How this form was filled:

Our AI extracted complex policy details from an insurance agent's internal email and intelligently filled out the ACORD 25 form. The AI correctly assigned multiple insurers to their respective policies, parsed various liability limits, and identified special provisions like Additional Insured and Waiver of Subrogation status.

Source document used: Insurance Agent's Internal Email

Hi Tom,

Please issue a new Certificate of Liability Insurance for our client, Apex Construction Inc. Their address is 123 Industrial Way, Suite 400, Boulder, CO 80301. The certificate needs to be dated for today, October 26, 2025. Please use cert number CERT-2025-987, revision 0.

The certificate holder is Urbanscape Properties LLC, located at 45 Park Avenue, Denver, CO 80202. They must be listed as an Additional Insured on the General Liability and Umbrella policies. Also, a Waiver of Subrogation is required for GL, Auto, and WC, as per their contract for the 'Parkside Tower construction project'. Please add this project name to the description.

Here are the policy details you'll need:

Commercial General Liability is with Granite State Assurance (NAIC #11111). It's an occurrence policy, #GCP-987654321, effective 06/01/2025 to 06/01/2026. Limits are $1M per occurrence, $2M general aggregate, $2M products/completed operations aggregate, $100k for damage to rented premises, $5k for med ex, and $1M for personal injury. The general aggregate applies per project.

Their Auto policy is with Patriot National Indemnity (NAIC #22222), policy #BAP-12345ABC, covering any auto with a $1M combined single limit. Same policy period.

The Workers' Comp is through Summit Workers Comp Co. (NAIC #33333), policy #WC-8889900. Limits are statutory, but Employers' Liability is $1M/$1M/$1M. All officers are included, so mark 'N' for the exclusion question. The dates match the others.

Finally, they have an Umbrella policy with Aegis Excess & Surplus (NAIC #44444). It's an occurrence policy, #UMB-5556677, with limits of $5M each occurrence and $5M aggregate. Policy dates are also June 1, 2025, to June 1, 2026.

I'll be the authorized representative on this. All our producer contact info for Keystone Insurance Group (555 Insurance Plaza, Denver, CO 80203) should be standard. My direct line is 303-555-0101 ext 25, fax is 303-555-0102, and email is [email protected]. Let me know once it's sent.

Thanks,
Sarah Jenkins

Information used to fill out the document:

  • Insured: Apex Construction Inc., 123 Industrial Way, Suite 400, Boulder, CO 80301
  • Certificate Holder: Urbanscape Properties LLC, 45 Park Avenue, Denver, CO 80202
  • Producer: Keystone Insurance Group, Sarah Jenkins
  • General Liability Policy: Policy #GCP-987654321, $1M Occurrence / $2M Aggregate
  • Automobile Liability Policy: Policy #BAP-12345ABC, $1M Combined Single Limit
  • Umbrella Policy: Policy #UMB-5556677, $5M Occurrence / $5M Aggregate
  • Workers' Comp Policy: Policy #WC-8889900, Statutory Limits, EL $1M/$1M/$1M
  • Special Provisions: Certificate Holder is Additional Insured on GL/Umbrella; Waiver of Subrogation on GL/Auto/WC

What this filled form sample shows:

  • Identified four distinct insurers and their NAIC numbers, assigning each to the correct coverage type (CGL, Auto, WC, Umbrella).
  • Extracted complex liability limit structures, including per occurrence/aggregate, combined single limit (CSL), and statutory limits.
  • Correctly interpreted narrative instructions like 'Certificate Holder is an Additional Insured' and 'Waiver of Subrogation is required' and applied them to the appropriate policies.
  • Parsed and mapped full address details for the Producer, Insured, and Certificate Holder from prose.
  • Handled specific form logic, such as marking 'N' for the officer exclusion based on the text 'All officers are included'.

Form specifications and details:

Use Case: Construction contractor providing a Certificate of Insurance to a property developer client.
Source Document: Insurance Agent's Internal Email
Categories: insurance forms, ACORD forms
Created: March 11, 2026 04:31 AM
Completed ACORD 25 Certificate of Liability Insurance for a construction company